What happens when a person becomes preoccupied with a perceived flaw in their appearance? For the general public this individual may just be having issues with their appearance and they’ll possibly forget about the issue a few moment/days/months later. If this perceived flaw then grows to create clinically significant distress or impairments in functioning, the individual may be suffering from a diagnosable disorder know as Body Dysmorphic Disorder. An individual suffering from BDD normally has impairments in their general ability to perform interpersonal or professional tasks originating from a perceived flaw (American Psychiatric Association, 2013). BDD has been shown to affects individuals’ thoughts, beliefs, and feelings, which is why it has been targeted by many researches as a disorder that benefits from cognitive-behavioral models of treatment. However, the disorder has had its fair share of issues and confusions because it has similarities to other disorders such as eating disorders, obsessive-compulsive disorders, and psychotic disorders.
Social workers have increasingly become one the most important individuals when assessing, educating, and advocating for disorders, however many are not as knowledgeable about BDD. This is partly due to the lack of research on the subject and the variety of treatments created for it. The reason BDD should concern social workers is because BDD creates significant impairments in occupational, academic, and social areas of functioning (Wolrich , 2011).
Assessing BDD can result in confusion between BDD, eating disorders, and obsessive-compulsive behaviors. Ultimately, there is much to be understood about BDD and it’s relationship to cognitive-behavioral treatments.
So what are cognitive-behavioral treatment models? Cognitive-behavioral treatment models follow the ideas presented by cognitive-behavioral theory. Contemporary cognitive-behavioral theory is rooted in the principle that a person’s cognition plays a primary role in the development and maintenance of emotional and behavioral responses to life’s circumstance (Gonzalez-Prendes & Resko, 2012). In cognitive-behavioral theoretical models, cognitive processes are the determining factors of a person’s feelings and actions in response to life events and in turn enable or hamper the process of adaptation (Gonzalez-Prendes & Resko, 2012). Within cognitive-behavioral theory there are three definitive principles that are essentially the foundation for any cognitive-behavioral treatments.
The first assumption of cognitive-behavioral (CB) theories is that the processes and content are accessible. The assumptions can seem rather vague but it infers that the process and content of a person’s cognition are discoverable by both the individual and the clinician (Gonzalez-Prendes & Resko, 2012). The ambiguity of this first assumption has caused some concern with identifying a foundation for CB therapy, but with the proper training a clinician can assist an individual in identifying those specific thoughts or beliefs to bring them to the forefront of any cognitive-behavioral treatment (Gonzalez-Prendes & Resko, 2012). The second key assumption of CB theory is that our thinking adjudicates the way that we respond to the environment (Gonzalez-Prendes & Resko, 2012). This is probably the most prominent of the CB theoretical assumptions that has been popularized in in almost every publication regarding cognitive behavioral therapies. CB theory assumes that the way people think about their reality is central to how they react to that reality. In CB theory people don’t just do things impulsively or emotionally charged. The third fundamental assumption of CBT is that cognitions have the ability to be adjusted or changed. Ultimately, when the cognitions are changed to be more realistic and rational the individuals’ symptoms should begin to be relieved. The goal for most cognitive-behavioral theoretical approaches to treatment is that the person will have increased adaptability and functionality.
Cognitive-behavioral theories are best conceptualized as an umbrella of set theories, which have evolved from the “theoretical writings, clinical experiences, and empirical studies of behavioral and cognitively oriented psychologists” (Gonzalez-Prendes & Resko, 2012). It is because of its ability to tackle several issues and its variance in actualized practice there is no single definition of cognitive-behavioral theory. The individual theories are tied together by the common assumptions previously mentioned, but argue a variety of viewpoints about the role cognitions can play in behavior change. Gonzales-Prendes and Resko interestingly explain that the term cognitive-behavioral is usually hyphenated whenever mentioned because it reflects the importance of both behavioral and cognitive approaches to understanding and helping human beings (2012). They write that the hyphen “brings together behavioral and cognitive theoretical views, each with its own theoretical assumptions and intervention strategies” (2012).
Cognitive-behavioral models of treatment target cognitive-behavioral problems using an integration of both cognitive and behavioral strategies (Veale, 2001). As discussed previously, cognitive-behavioral research is based on observed changes in behavior and cognition with specific attention to methodological changes in a person. Cognitive-behavioral theories are interesting in that they provide flexibility in treatment for both the target of treatment and the actual treatment method. CB theoretical based models of treatment share a fundamental emphasis on the importance of the cognitive inner-workings of a person and individual-specific events that have the ability to facilitate of behavioral changes. A behavioral assessment provides a conceptual model for relationship between thoughts, behaviors, and feelings (Gonzalez-Prendes & Resko, 2012). A thorough understanding of the intersection between thoughts, behaviors, and feelings provides the necessary background for clinicians and researchers to implement and evaluate CB theories in practice. Currently there are wide varieties of cognitive-behavioral intervention techniques and with its growing popularity and research the number is likely to grow.
Contemporary cognitive-behavioral theory is imbedded within treatment for BDD, but before one can understand the treatment they must first understand the disorder. BDD was recategorized in the DSM-5 as an obsessive-compulsive-related disorder. This does not mean that BDD is an obsessive-compulsive disorder, but the two are related in terms of symptomatology. There are four diagnostic criteria that necessary for a BBD diagnosis. Additionally there are a couple of specifiers clinicians can use to conceptualize and better treat patients with BDD.
According to the American Psychological Association, the first of the criteria for BDD is the preoccupations with appearance. An individual with BDD must be preoccupied with one or more nonexistent or slight defect/flaw in their physical appearance (American Psychiatric Association, 2013). The DSM clarifies that individuals must be thinking about their appearance at least four times a day to be considered “preoccupied” with their appearance (American Psychiatric Association, 2013).. There are some differentiations made by the DSM within the BDD diagnosis. If a person is having issues within obvious flaws in appearance, they may likely have an different obsessive-compulsive diagnosis, but not BDD because their flaw is blatantly present and observable to all (American Psychiatric Association, 2013).
According to the DSM, the second criteria for a BDD diagnosis states that an individual installs repetitive behaviors into their normal routines (American Psychiatric Association, 2013). A person with BDD will usually perform repetitive and compulsive behaviors in response to the appearance concerns. These behaviors are normally easily observable to others. Some examples of these behaviors include mirror checking, make-up touch ups, and in the modern age taking selfies and the constant checking of photos of oneself. Other concerns within the BDD diagnosis are compulsions in individuals’ thought processing like an individual consistently comparing themselves to other people. These compulsions are not necessarily visible and therefore are to be explored thoroughly by clinicians (American Psychiatric Association, 2013). Cognitive-behavioral theory is incredibly helpful in this aspect.
The third criterion for BDD is fairly vague but interesting as it involves the clinical significance of an individual’s compulsions (American Psychiatric Association, 2013). For BDD to be diagnosable, the compulsions a person is experiences must be causing some sort of impairment in their occupational, social, or other important areas of functioning. The third criteria of the BDD diagnosis helps clinicians differentiate the disorder from general appearance concerns (American Psychiatric Association, 2013). Some guidelines provided by the American Psychological Association for BDD note that a clinician should always check if an appearance concern is only about weighting too much or being too fat (American Psychiatric Association, 2013). Sometimes these concerns should lead to a discussion regarding an eating disorder and less about BDD (Wolrich, 2011).
Specifiers act as extensions to a particular diagnosis and help clarify the progression, rigorousness, or special features of a given disorder (American Psychiatric Association, 2013). In BDD, there are two significant specifiers that assist the diagnosis. The first specifier is muscle dysmorphia where an individual’s primary concerns revolve around the idea that their build is inadequately muscular (American Psychiatric Association, 2013). Studies have shown that individuals with the muscle dysmorphic version of BDD have higher rates of suicide and substance abuse disorders as well as lower qualities of life than those with general BDD (Buhlmann, 2012).There is also an insight specifier that asks that individuals with BDD be assessed for how convinced he/she is in his/her belief about their perceived flaw in appearance (American Psychiatric Association, 2013). The levels of insight, according to the American Psychological Association, are good, fair, poor, absent, or delusional (American Psychiatric Association, 2013). The DSM also notes that individuals with delusional beliefs or absent insight be diagnosed as a portion of BDD and not as a separate psychotic disorder (American Psychiatric Association, 2013).
Something that is predominantly present in BDD is that an individuals have certain beliefs and those thoughts are at the center of a their behaviors and emotions. BDD is in nature an almost perfect fit for being understood through the lens of cognitive-behavioral theory. A BDD diagnosis has three main criteria there somewhat mimic the intersection of thoughts, feelings, and behaviors within cognitive-behavioral theories. It follows suit that researchers continuously look at the relationship between BDD and CBT. There have been multiple models created using cognitive-behavioral theory to address BDD.
The cognitive–behavioral model for treating BDD uses a three-systems analysis that concentrates on the factors that maintain the disorder (Veale, 2001). Many of these assessments focus particularly on beliefs and behaviors of the disorder. Since those with BDD are generally concerned with portions of their bodies it is important to ask them specifically about which parts so that CBT can be used to target the thoughts about that specific body part (Veale, 2001). Since the nature of the disorder can change over time it’s also important to use cognitive-behavioral theories to monitor changes in the individuals’ thoughts and beliefs about their perceived imperfections over time (Veale, 2001). Veale writes that the following step in CBT treatment for BDD is to assess the personal meaning or the assumptions held about the perceived defect or ugliness (2001).
Patients may have difficulty in articulating the meaning, but usually the therapist can elicit the most dominant emotion associated with thinking about the defect and later can ask what is the most concerning or anxiety-provoking aspect about the defect (Veale, 2001). For example, one patient might believe perceived defect about his/her nose that leads him to feeling unworthy of affection or love. An assumption like this would then be used to create a plan for cognitive restructuring and behavioral experiments. Values are important here because the patient has to feel in control of their treatment, meaning the therapist has to work with the individual identifies as the most important thing. In BDD, appearance is usually the dominant and idealized value and can definitely be someone defining characteristic. Veale writes that patients implicitly view themselves as ‘aesthetic objects’ (2001).
Body Dysmorphic Disorder has a mind-body connection that has a bi-directional impact on health and mental health. By nature BDD is involved with a person’s appearance, which includes physical health conditions that may or may not be real. The preoccupation an individual has toward their appearance and physical health leads to distress that affects the individuals mental health. Therefore, by nature the disorder is forever linked to the individuals’ mind-body connection. Also, BDD treatments’ utilize a persons’ identified thoughts, emotions, and behaviors to tackle issues of the mind that impact the individuals overall health. For example, if a person’s BDD stems from some unhappiness in the size of their arms, them individual will stress and concentrate on perfecting this perceived issue. This stress, rooted in the persons’ mental health disorder, in turn has a bidirectional impact on the person’s health outcomes (Basham, Byers, Heller, Hertz, Kumaria, Mattei et al., 2016). These outcomes can be both good and bad because the individual might begin working out a lot more and remaining physically healthy while the stress behind those actions increases the persons’ cortisol and adrenaline levels to mimic the same levels that are present in individuals who suffer from chronic stress.
Neurobiology is one of the areas of BDD research that has added a lot to the discussion of treatment for BDD. Thilo Deckersbach and his colleagues have studied BDDs affects on the brain and have come to some interesting conclusion about how BDD affects memory. In their study, Deckersback et al. asked participants to reproduce a complicated figure that they were shown. The participants with BDD focused on very specific parts of the drawing while those who didn’t have BDD focused on the drawing as a whole. The results from this study suggested that those with BDD may have visual memory deficits as a result of having an imbalance in thought processing between detailed and generalized information. The results also suggest some cognitive deficits, which have been best treated with cognitive-behavioral theory-based models.
In a study conducted regarding executive function and body dysmorphic disorder, J. Dunai and colleagues found that those with BDD have do unfavorably in tasks such as planning, organization, and general inhibition. The study inferred that individuals diagnosed with BDD were slower and made more mistakes on tasks measuring the abilities related to organization and planning showing some deficits in the individuals working memory. Again, these deficiencies in memory are linked to the individual’s cognition, which has again been linked to treatments grounded in cognitive-behavioral theory.
Memory isn’t the only neurobiological effect of BDD. Emotional processing has also been affected by BDD. A study conducted by Ulrike Buhlmann found that individuals with BDD have difficulty recognizes the emotions presented through facial expression. An interesting aspect from the study was that individuals with BDD would identify many facial expressions as contemptuous and angry while healthy controls were seemingly able to identify the emotions without faults. These concerns regarding a person’s ability to identify expression is linked to the temporal lobe and in turn may identify a link between the brain and BDD. Buhlmann and her colleagues also conducted a study elaborating on relationships between individuals with BDD and individuals without BDD. The study found that individuals with BDD found situations of ambiguity more threatening than an individual without BDD. They didn’t elaborate as to why this occurred, but utilizing cognitive-behavioral theories a clinician would want to explore the individuals’ thoughts and beliefs around ambiguous situations to work on an appropriate response.
Donatella Marazziti conducted a more in depth study on neurochemicals and BBD. The study found people with BDD had decreased serotonin densities when compared to a healthy control group (Marazziti, Dell’Osso, and Presta, 1999). A treatment model created from this assumption has been the prescription of serotonin reuptake inhibitors. Serotonin reuptake inhibitors decrease BDD symptoms including reduced worrying about appearance. These reuptake inhibitors also helped relieve BDD-related emotional distress, which in turn lessened the frequency of social anxiety (Phillips, Didie, Feusner, and Wilhelm, 2008). These studies did not prove that serotonin levels decide a BDD diagnosis, however it does provide some valuable information to consider when discussing the neurobiology of BDD.
More research should be completed to see if stress related to BDD is affecting the hippocampus and ultimately triggering issues within memory processing. Stress has been shown to inhibit memory processing because of the amplified release of adrenaline and cortisol (Cozolino, 2017). The high volumes of these chemicals within the HPA axis have been proven to consistently raise blood pressure and limit cognitive processing, including the affects on the hippocampus and possibly the temporal lobe and amygdala for issues processing the display of emotions (Cozolino, 2017). It would be reasonable to conclude that the stress related to BDD would have impacts on a person’s ability to recall and process new memories.
Cognitive-behavioral theories are rooted in the treatment of BDD. Most models of cognitive-behavioral theory incorporated the biological, psychological, and sociocultural factors that facilitate and maintain BDD. Cognitive behavioral therapy is the most prominent treatment for BDD. The process of utilizing it asks that the individual who is in therapy for BDD to attend to the minor aspects of their appearance in order to target a specific thoughts, emotions, or belief. It’s important to keep the approach person-centered because in this treatment because it eventually form a foundation for self-help and self-regulating behaviors.
There is no definitive time frame set for CBT in the treatment of BDD, but there are pretty important beginning and ends to the treatment that are defined by both the clinician and client. Typically cognitive-behavioral therapy begins with the assessment of the client and the psychoeducation provided to the client about the treatment method they are about to start (Phillips, 2014). The following steps taken in CBT treatment are completely client-centered as the treatment method can modulate depending on the patient. Some routes that the treatment can take include cognitive restructuring, exposure and ritual prevention, and lastly relapse prevention (Wilhelm et al., 2014).
Cognitive behavioral therapy works to reconstruct cognitions, which is why it will often begin with identifying maladaptive thoughts (Gonzalez-Prendes and Resko, 2012). Once those thoughts are identified, the clinician works to evaluate these thoughts and introduces the individual to some common cognitive errors that their disorder may be causing (Veale, 2001). Cognitive errors within treatment for BDD usually involve splitting or misdirected opinions, where the clients have an all-or-nothing approach to thinking about people’s perceptions of them (Cozolino, 2017). Once the client has begun to build a threshold for their maladaptive thoughts and cognitive errors the clinician should evaluate the clients’ ability to tackle the negative thoughts, feelings, and behaviors stemming from their disorder. Ultimately, the client will be exposed the maladaptive thoughts and cognitive errors as a way to form rituals to prevent the behaviors that come from their disorder.
Lastly, the treatment should end with relapse prevention focused on strengthening the individuals’ skills and creating a plan for the future (Veale, 2001). Clinicians can give the patient hypothetical problems and allow them to discover the proper tools to combat the issue without having negative thoughts, feelings, or behaviors (Wolrich, 2011). At this point in treatment the patient should be able to self-regulate or self–therapy where the client sets time aside usually every week to review skills and set upcoming BDD goals (Veale, 2001). Booster sessions have also been noted as a part of treatment where there is a meeting with the therapist to periodically assess progress and review CBT skills (Wilhelm et al., 2013).
Gender has often been one of the largest differentiations in studies done to further understand BDD. Groups are usually split by gender to understand the complexities of BDD. These studies have varied widely in their responses, but have generally come to the same conclusion. BDD affects both genders equally, however the specific nature of the BDD is usually tied to cultural norms and beliefs. In a 2008 university study on BDD, students found that the male to female ratio for BDD was 1:7 (Taqui, Shaikh, Gowani, Shahid, Khan, Tayyeb, Satti, Vaqar, Shahid, Shamsi, Ganatra and Naqvi, 2008). In the study the top three reported foci of concern in male students were “head hair (34.3%), being fat (32.8%), skin (14.9%) and nose( 14.9%), whereas in females they were being fat (40.4%), skin (24.7%) and teeth (18%)” (Taqui et al, 2008). The study found that females were more concerned about being fat while males were more concerned about how their hair looked and making sure they didn’t look too thin (Taqui et al., 2008). Similar studies have been done for multiple races and ethnicities, finding culture as one of the most pertinent and deciding factors about BDD concerns. Culture and appearance are ever changing; therefore approaches to BDD should consider these cultural differences to assure proper treatment.
Body Dysmorphic Disorder affects anywhere from 1.7% to 2.4% of the general population, which means that more than 5 million people to about 7.5 million people in the United States alone are diagnosed or have undiagnosed BDD (Phillips, 2014; “BDD for Professionals”, 2014). With these numbers, BDD is about as common as obsessive-compulsive disorder and more common than most eating disorders (Phillips, 2014; “BDD for Professionals”, 2014). It is possible that BDD may be even more prevalent than this because people with this disorder are often reluctant to reveal their BDD symptoms to others (Wolrich, 2011). Because of its prevalence BDD is a disorder that should continuously be studied and approaches to its treatment should be consistently reviewed. Cognitive-behavioral theory lends itself to a multitude of approaches and although cognitive-behavioral therapy is the most common treatment for BDD, there are specificities that can be done to it per individual given the variance in causes of BDD.
According to the NASW Code of Ethics, social workers have a responsibility to learn about these disorders and issues as they become relevant to the profession, and BDD has definitely become an area that should garner our attention. As mentioned previously, BDD can have several sociocultural influences and therefore remains within a clinicians or social workers scope of practice. Increased awareness and a more developed understanding of BDD can enhance social workers’ abilities to acknowledge and hopefully treat this population (Wolrich, 2011). Ultimately social workers can be at the forefront in facilitating the identification of BDD symptomatology and the delivery of appropriate and effective assessment, diagnosis, psychoeducation, and treatment (Wolrich, 2011). With a greater understanding of BDD, social workers can create significant changes in program development for BDD as well as influence social policies that directly impact this population. If anything, social workers should remain ready to talk about disorder such as BDD to provide effective treatment to those who need it.
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